VA FORM SEP 2016 21-0960C-11

SEIZURE DISORDERS (EPILEPSY) DISABILITY BENEFITS QUESTIONNAIRE

NAME OF PATIENT/VETERAN (First, Middle Initial, Last)

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SEIZURE DISORDER (epilepsy)? (This is the condition the veteran is claiming or for which an exam has been requested)

OMB Approved No. 2900-0781 Respondent Burden: 15 Minutes Expiration Date: 09/30/2019

1B. SELECT THE APPROPRIATE DIAGNOSIS: (check all that apply):

(If "Yes," complete Item 1B)

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.

(If "Yes," list only those medications required for the veteran's epilepsy or seizure activity)

JACKSONIAN (simple partial seizures)FOCAL MOTOR

ABSENCE SEIZURES OR PETIT MAL OR ATONIC SEIZURES (generalized non-convulsive seizures)

FOCAL SENSORY

SECTION III - MEDICAL HISTORY

SECTION II - MEDICAL RECORD REVIEW

Page 1SUPERSEDES VA FORM 21-0960C-11, OCT 2012, WHICH WILL NOT BE USED.

NO

OTHER (specify)

DIENCEPHALIC EPILEPSY

TONIC-CLONIC SEIZURES OR GRAND MAL EPILEPSY (generalized convulsive seizures)

PSYCHOMOTOR EPILEPSY (complex partial seizures, temporal lobe seizures)

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SEIZURE DISORDERS (epilepsy), LIST USING ABOVE FORMAT:

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.

SECTION I - DIAGNOSIS

3C. HAS THE VETERAN HAD ANY OTHER TREATMENT (such as surgery) FOR EPILEPSY OR SEIZURE ACTIVITY?

3D. HAS THE DIAGNOSIS OF A SEIZURE DISORDER BEEN CONFIRMED?

3A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SEIZURE DISORDER (epilepsy) (brief summary):

YES

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF EPILEPSY OR SEIZURE ACTIVITY?

NOYES

(If "Yes," describe):NOYES

Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:

ICD Code: Date of diagnosis:

ICD Code: Date of diagnosis:

ICD Code: Date of diagnosis:

ICD Code: Date of diagnosis:

ICD Code: Date of diagnosis:

ICD Code:

Date of diagnosis:ICD Code:

Date of diagnosis:

YES NO (If "Yes," describe):

3E. HAS THE VETERAN HAD A WITNESSED SEIZURE?

YES NO (If "Yes," describe, including relationship of witnesses to veteran):

Other diagnosis #2

Other diagnosis #1

2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:

C-FILE (VA ONLY)

OTHER, DESCRIBE:

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the "Remarks" section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an appropriate date determined through record review or reported history.

VA FORM 21-0960C-11, SEP 2016 Page 2

4. DOES THE VETERAN HAVE OR HAS HE OR SHE HAD ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SEIZURE DISORDER (epilepsy) ACTIVITY?

Episodes of sudden jerking movement of the arms, trunk or head (myoclonic type)

Episodes of tremors

Episodes of visceral manifestations

Residuals of Injury during seizure

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS

Episodes of speech disturbances

Episodes of perceptual illusions

Other

(For all checked conditions describe):

5D. HAS THE VETERAN EVER HAD MAJOR SEIZURES (characterized by the generalized tonic-clonic convulsion with unconsciousness)?

5C. HAS THE VETERAN EVER HAD MINOR SEIZURES (characterized by a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head ("pure" petit mal) or sudden jerking movements of the arms, trunk or head (myoclonic type) or sudden loss of postural control (akinetic type))?

5B. PROVIDE APPROXIMATE DATE OF FIRST SEIZURE ACTIVITY (Month, Year)

PROVIDE DATE OF MOST RECENT SEIZURE ACTIVITY (Month, Year)

5.A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER HAD ANY TYPE OF SEIZURE ACTIVITY, INCLUDING MAJOR, MINOR, PETIT MAL OR PSYCHOMOTOR SEIZURE ACTIVITY?

Episodes of sudden loss of postural control (akinetic type)

NO

Episodes of impairment of vision

Episodes of complete or partial loss of use of one or more extremities

YES

Episodes of hallucinations

(If "Yes," check all that apply)

Generalized tonic-clonic convulsion

Episodes of unconsciousness

Brief interruption in consciousness or conscious control

Episodes of staring

Episodes of rhythmic blinking of the eyes

Episodes of nodding of the head

NOYES

Episodes of random motor movements

SECTION V - TYPE AND FREQUENCY OF SEIZURE ACTIVITY

Episodes of psychotic manifestations

Episodes of abnormalities of thinking

Episodes of abnormalities of memory

Episodes of abnormalities of mood

Episodes of disturbances of gait

Episodes of autonomic disturbances

At least 1 in past 2 years At least 2 in past yearNone in past 2 years

Less than 1 in past 6 months

At least 1 in past 6 months

At least 1 in 4 months over past year

At least 1 in 3 months over past year

At least 1 per month over past year

NOYES

(If "Yes," complete Items 5B through 5H)

(If "Yes," complete the following):

(If "Yes," complete the following):

NOYES

Number of minor seizures over past 6 months:

Number of major seizures:

Average frequency of major seizures:

0-1

0-4 per week 5-8 per week 9-10 per week More than 10 per week

2 or more

If 2 or more over the past 6 months, indicate the average frequency of minor seizures:

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - TYPE AND FREQUENCY OF SEIZURE ACTIVITY (Continued)

VA FORM 21-0960C-11, SEP 2016 Page 3

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

SECTION VII - DIAGNOSTIC TESTING

7A. HAVE ANY IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED?

7B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?Other (describe):

(If "Yes," check all that apply)

YES NO (If "Yes," provide type of test or procedure, date and results (brief summary)):

(If "Yes," describe (brief summary)):

NOYES

NOTE - If diagnostic test results are in the medical record and reflect the veteran's current seizure (epilepsy) disorder, repeat testing is not required.

6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION?

5G. HAS THE VETERAN EVER HAD EPILEPSY ASSOCIATED WITH A NONPSYCHOTIC ORGANIC BRAIN SYNDROME?

5H. HAS THE VETERAN EVER HAD EPILEPSY ASSOCIATED WITH A PSYCHOTIC DISORDER, PSYCHONEUROTIC DISORDER OR PERSONALITY DISORDER?

6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

Magnetic resonance imaging (MRI)Computed tomography (CT)

Electroencephalography (EEG)Cerebrospinal fluid CSF examination

Neuropsychologic testing

Date:

Date:

Date:

Date:

Date:

Results:

Results:

Results:

Results:

Results:

Results:Date:

YES NO

5F. HAS THE VETERAN EVER HAD MAJOR PSYCHOMOTOR SEIZURES (major psychomotor seizures are characterized by automatic states and/or generalized convulsions with unconsciousness)?

5E. HAS THE VETERAN EVER HAD MINOR PSYCHOMOTOR SEIZURES (characterized by brief transient episodes of random motor movements, hallucinations, perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances)?

NOYES

At least 1 in past 2 years

At least 2 in past year

None in past 2 years

Less than 1 in past 6 months

At least 1 in past 6 months

At least 1 in 4 months over past year

At least 1 in 3 months over past year

At least 1 per month over past year

(If "Yes," complete the following):

YES NO (If "Yes," describe):

YES NO (If "Yes," the appropriate Mental Disorder Questionnaire must ALSO be completed)

Number of major psychomotor seizures:

Average frequency of major psychomotor seizures:

NOYES (If "Yes," complete the following):Number of minor seizures over past 6 months:

0-1

0-4 per week 5-8 per week 9-10 per week More than 10 per week

2 or more

If 2 or more over the past 6 months, indicate the average frequency of minor seizures:

NOYES

IF "YES," ARE ANY OF THESE SCARS PAINFUL AND/OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR ARE LOCATED ON THE HEAD, FACE, OR NECK?

NOYES

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).IF "NO," PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS. LOCATION:__________________________________ MEASUREMENTS: Length_____________ cm X width _____________ cm.NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements in the "Remarks" section. It is not necessary to also complete a Scars/Disfigurement DBQ.

PATIENT/VETERAN'S SOCIAL SECURITY NO.

9. REMARKS (If any)

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

8. DOES THE VETERAN'S EPILEPSY OR SEIZURE (epilepsy) DISORDER IMPACT HIS OR HER ABILITY TO WORK?

(If "Yes," describe the impact of the veteran's seizure (epilepsy) disorder, providing one or more examples):YES NO

SECTION VIII - FUNCTIONAL IMPACT

SECTION IX - REMARKS

Page 4VA FORM 21-0960C-11, SEP 2016

 CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current. 10C. DATE SIGNED

10E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 10F. PHYSICIAN'S ADDRESS

10B. PHYSICIAN'S PRINTED NAME

10D. PHYSICIAN'S PHONE/FAX NUMBERS

10A. PHYSICIAN'S SIGNATURE

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.

IMPORTANT - Physician please fax the completed form to:

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. RESPONDENT BURDEN:  We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

PATIENT/VETERAN'S SOCIAL SECURITY NO.